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Home My Public Portal About5553-5553 1/2 SANTA ANITA AVE_Building__ WORKERS'COMPENSATION DECLARATION hereby,affirtn that I have a certificate of consent to self A•� Lal CAT I.0.-N -'F Q•R BUILDING PERMIT . � insure, or a•'certificate of Workers'Compensation Insurance, \ o'r a certified copy tiler o Sec. 3800, Lab. Ct) �w ZODY ��1p C' .-COUNTY OF�LOS.ANGELES; BUILDING AND SAFETY Policy No. Company -' Certified copy is hereby furnished. FOR APPLICANT TO FILL IN BUILDING ADDRESS SJJ Z A1I WCertified copy is filed with the county building inspec- BUILDING tion dep`arttmment. ADDRESS 5553 1/2 Santa Anita Ave. Date /1� a ` Applicant CITY Temple City zip 91780 LOCALITY CERTIFICATE OF EXEMPTION FROM WORKERS NO.OF BLDGS. NEAREST COMPENSATION INSURANCE SIZE OF LOT NOW ON LOT CROSS ST. (This section need not be completed if the permit is for one 44319 - ASSESSOR hundred dollars ($100)or less.) TRACT BLOCK LOT NO. MAP BOOK PAGE PARCEL OWNER J.E. Plount & Co. TEL. —8737 U TEL. SE ONE OP /S n I certify that in the performance of the work for which this _ 77 permit is issued,.I shall not employ any person in any manner SPECIAL G° so as to become subject to the Workers'Compensation Laws. ADDRESS 217 W CONDITIONS V CITY 0 Gabriel ZIP Date Applicant ARCHITECT OR TEL DISTRICT GROUP TYPE FIRE PRO SSED BY NOTICE TO APPLICANT: If, after making this Certificate of ENGINEER Neil Esurki NO576-7456 Exemption, you should become subject to the -Workers' -� CONST. ZONE Compensation provisions of the Labor Code, you must forth- ADDRESS °W - y 3 with comply with such provisions or this permit shall be TEL.. _T STATISTICAL C IN ATION y/ APT. ONDO. Z deemed revoked. CONTRACTOR Same as owner NO LICENSED CONTRACTORS DECLARATION LIC. CLASS NO. �DWELL. UNITS I hereby affirm that I am licensed under provisions of Chapter 9 ADDRESS NO. SEWER MAP (commencing with-Section 7000)of Division 3 of the Business and LIC. Professions Code, and my license is in full force and effect. CITY CLASS BK._ VALIDATION Q SQ.FT• 1735 NO.OF �] NO.OF CHECK License Number 3/�Z/ & /LLi�c.Class ` SIZE STORIES /`� FAMILIES ONE TZ S�04/r/T >�•mate VALUATION Contractor DESCRIPTION OF WORK NEW $ `'Q Z)if 4 3 3 2 A I am exempt under Sec. >—� single family detached ADD (J (/ , #•e o o o 2 3 ALTER ❑ B.&P.C. for this reason condominium.+ ff^C REPAIR ❑ $ I o633,05 Date: USE OF EXISTIING BLDG. DEMOL ❑ a a 633,0577 Signature APPLIPCANT John Plount TEL 576-8737 FINAL OWNER-BUILDER DECLARATION RINT) NO. DATE o3.31 —86 1 hereby affirm that I am exempt.from the Contractor's License217 W. Las Tunas San Gabreil Law for the following reason (Section 7031.5, Business and ADDRESS FI Professions Code): PRESENT B ❑ I, as owner of the property, or my employees with ADDRESS wages as their sole compensation,will do the work and ' the structure is not intended or offered for sale(Section LOCALITY 7044, Business and Professions Code). MOVING TEL. A 5 0 3.8 A ❑ I,as owner of the property, am exclusively contracting CONTRACTOR NO. with licensed contractors to construct the project (Sec- ADDRESS # 0 0 0 0 0 1 tion 7044, Business and Professions Code). REQUIRED TOTAL SETBACK FROM ' CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE WIDTH 0 7 5 5 2 5 I hereby affirm that there is a construction lending agency for FRONT the performance of the work for which this permit is issued P.L. o 0 7 5 5 2 5 (Sec. 3097, Civ. C.). SIDE a P.L. 7..1 5 —8 6 Lender's Name (� LDMA Ref.#, ' P.C.Fee$ 3 3I(/v Permit Fee ' Lender's Address I certify that.[ have read this application and state that the Issuance Fee LDMA P/C# ' above Information is correct. I agree to comply with all County Investigation Fee ordinances and State laws relating to building construction, Total Fee s LDMA perm. # and hereby authorize representatives of this County to enter ( upon the above-mentioned property for inspection purposes. t ��t � SEE REVERSE FOR EXPLANATORY LANGUAGE ' Signature pplicant or Agent Date - 0� WORKERS!COMQENSATION DECLARATION 4,hereby affirm that I have a certificate of consent to self ti insure, or arcertificate of Workers'Compensation Insurance, \,` ,�• • ti .t'P T•�' '; ` �� aR BUILDING PERMIT ora;certified copy thRr��Of(Sec. 3800, lab. C.) OUNTY.OF LOS_ ANG,ELES_4 BUILDING AN SAFETY Y d p (� Policy No. �� Com any � `p - �� - � BUILDING ❑ Certified copy is hereby furnished. FOR APPLICANT TO FILL IN ADDRESS S.S-_5 'Certified copy is filed with the county building inspec- BUILDING tion department. ADDRESS 5553 Santa Anita Ave. - U Date Applicant CITY ZIP LOCALITY. CERTIFICATE OF EXEMPTION FROM WORK S' NO:OF BLDGS. - NEARE81 COMPENSATION INSURANCE SIZE OF LOT NOW ON LOT CROSS ST. (This section need not be completed if the permit is for one TRACT 44319 BLOCK LOT NOASSESSOR. . hundred dollars($100)or less.,) MAP BOOK PAGE PARCEL J.E. Plount & CO. TEL-576-8737 USE ONE MAP r " ASO- 1,certify that in the performance of the work for which this OWNER NO. NO• a7 permit is issued,I shall not employ any person in any manner - �7^ SPECIAL so as•td.becothe subject to the Workers"Compensation Laws. ADDRESS 21.7 W. Las -Tunas DR. �✓ CONDITIONS CITY San Gabreil TIP 91776 _. Date Applicant 09 ' NOTICE TO APPLICANT: ARCHITECT OR TEL.If, after making this Certificate of Neil Esurki 576-7456 DISTRICT G UP TYPE FIRE PROCES ED BY . , ENGINEER NO. �J�( CONST.V / ZOjyE Exemption, you should become subject to the- Workers' 54) _ �V/ ✓/, g+g Compensation provisions of the Labor Code, you must.forth ADDRESS y with comply.with such provisions or this,permit shall, be TEL. "' STATISTICAL CLASSIFICATION APT. CO r deemed,revoked: CONTRACTOR same as owner NO. ,L J LICENSED CONTRACTORS DECLARATION LIC. CLASS NO. UUVELL..UNITS -1—L hereby affirm,that I am licensed under provisions of Chapter 9 '' ADDRESS NO. SEWER MAP (commencing with Section 7000)of Division 3 of the Business and LIC. Professioi s'Code,and my license is in full farce and effect. CITY CLASSBK VALIDATION SQ.FT. 1613 NO.OF 2 NO.OF CHECK License N6mbter' Lic.Class_'Al SIZE STORIES FAMILIES ONE ,� DESCRIPTION OF WORK NEW. VALUATION U O o 6 P_4 33 1 A / Contractor 1C J0'Z9&yP 3% 6 Date $ IF single family detached ADD # ° ° 23 ❑I am exempt under Sec. ❑ 1 ALTER .- 'B.BP.C. for this reason rondominjilm ftS"t REPAIR ❑ $ ° 6 0 4,3 5 Date: USE OF DEMOL ❑ EXISTING BLDG. _ ._,'Signafiire APPLICANT TEL. FINAL �J ° ° 6 04.3 5 OWNER-BUILDER DECLARATION PRINT John PlOunt NO. DATE (/. $6 I herebyff airm that-I am exempt from the Contractor's License 3'"1 — 1 .Law for the following-reason (Section 7031.5, Business and ADDRESS 17 W. Lai Tunas San Gabriel. FI Professions Code):' PR SENT B ❑ BUILDING I, as owner of the property, or my employees with ADDRESS ' wages as their sole compensation,will'do the work and LOCALITY ; the structure is not intended or offered for sale(Section 7044, Business and Professions Code). MOVING .' TEL. ❑ I,-as owner of the'property,am exclusively contracting CONTRACTOR NO. with licensed contractors to construct the project (Sec- ADDRESS tion 7044, Business and Professions Code). REQUIRED TOTAL SETBACK FROV' CONSTRUCTION LENDING AGENCY SET BACK YARD HWY PROP. LINE WIDTH I hereby affirm that there is a construction lending agency for FRONT y A90-5 0 3.7 A the-performance of the work for which this permit is issued P.L. (Sec. 3097, Civ. C.). SIDE , '# 0 0 0:0 0 1 3 Y. Lender's Name P.L. l _ .! 1 'o 7 2 1.5 0 ° 0 ` �/ LDMA Ref. # 0 0 7 21.5 0 P.C.Fees u Permit Fee - Lender's Address rI certify.that I have read this application and state that the Issuance Fee. LDtAA P/C# T, ' �'± 113 above information is correct. I agree to comply with all County Investigation Fee t �:7. 1 5—8 6' S ordinances and State laws relating to building construction, Total Fee LDMA Perm.# and hereby authorize representatives of this County to enter 3 upon the above-mentio ed property for inspection purposes. SEE.REVERSE FOR EXPLANATORY LANGUAGE D , Signature� Applicant or Agent- Date - -- -- • - •• ®�